Healthcare Provider Details

I. General information

NPI: 1073594891
Provider Name (Legal Business Name): MOORSE DENTAL PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 W LINCOLN AVE
OLIVIA MN
56277-4215
US

IV. Provider business mailing address

907 W LINCOLN AVE
OLIVIA MN
56277-4215
US

V. Phone/Fax

Practice location:
  • Phone: 320-523-1441
  • Fax: 320-523-1441
Mailing address:
  • Phone: 320-523-1441
  • Fax: 320-523-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11030
License Number StateMN

VIII. Authorized Official

Name: MARK JOSEPH MOORSE
Title or Position: PRESIDENT
Credential: DDS
Phone: 320-523-1441